NURS 7215: Section 1 Review Questions

Which nursing intervention would be most helpful in managing a patient newly admitted with cellulitis of the right foot? A. Applying warm, moist heat B. Wrapping the foot snugly in blankets C. Keeping the foot at or below heart level D. Limiting ambulation to three times daily

A. Applying warm, moist heat Rationale: The application of warm, moist heat speeds the resolution of inflammation and infection when accompanied by appropriate antibiotic therapy. It does this by increasing local circulation to the affected area to bring macrophages to the area and carry off cellular debris. Immobilization and elevation is also used. Snug blankets would not be helpful and could decrease circulation to this sensitive tissue.

After the unlicensed assistive personnel (UAP) bathed the patient, she reported a reddened area on the patient's coccyx to the nurse. After assessing the area, what should be included in the plan of care? A. Reposition every 2 hours. B. Measure the size of the reddened area. C. Massage the area to increase blood flow. D. Evaluate the area later to see if it is better.

A. Reposition every 2 hours. Rationale: The most important thing to do for this patient is to prevent deterioration of the injury and eliminate factors that led to pressure injuries. This would include eliminating pressure on the reddened area with repositioning every 2 hours in bed and every hour while up in the chair. The nurse must complete the assessment of the new reddened area as well as evaluation of the area. Massage is not used when there is the possibility of damaged blood vessels or fragile skin, so the RN cannot advise the UAP to do this until the RN has assessed the patient and the area.

A patient admitted with heart failure is diagnosed with herpes zoster and draining vesicles. Which action, if observed by the nurse, would require additional teaching for that person? A. The dietitian wears a mask when entering the patient's room. B. The patient keeps the draining vesicles covered with a dressing. C. The UAP washes hands frequently and wears gloves when in the room. D. The student nurse who takes prednisone requests a new patient assignment.

A. The dietitian wears a mask when entering the patient's room. Rationale: Herpes zoster, or shingles, is spread by contact with fluid draining from the vesicles (not by coughing, sneezing, or casual contact). The risk of a person with shingles spreading the virus is low if the rash is covered. Wearing a mask would not prevent the spread of infection. Until the rash develops crusts, the patient should not have contact with an immunocompromised person (e.g., a person taking prednisone). Shingles is not contagious before the vesicles appear or after the vesicles have crusted over. Frequent hand washing helps to prevent the spread of varicella zoster virus.

The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation? (Select all that apply.) A. Urine output is 46 mL/hr. B. Heart rate is 94 beats/min. C. Urine specific gravity is 1.040. D. Mean arterial pressure is 54 mm Hg. E. Systolic blood pressure is 88 mm Hg.

A. Urine output is 46 mL/hr. B. Heart rate is 94 beats/min. Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, and heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.

A female patient with a history of rheumatoid arthritis reports of stiffness in her right knee and complete fixation of the joint. What problem should the nurse anticipate will be identified in the patient's history and physical examination? A. Atrophy B. Ankylosis C. Crepitation D. Contracture

B. Ankylosis Ankylosis is stiffness or fixation of a joint. Contracture is reduced movement as a consequence of fibrosis of soft tissue (muscles, ligaments, or tendons). Atrophy is a wasting of muscle leading to decreased function and tone. Crepitation is a grating or crackling sound that accompanies joint movement. Problem identification leads to determination of an appropriate treatment.

A patient is ordered to receive acetaminophen 650 mg per rectum every 6 hours as needed for fever greater than 102° F. Which priority parameter would the nurse monitor, other than temperature, if the patient requires this medication? A. Pain level B. Intake and output C. Oxygen saturation D. Level of consciousness

B. Intake and output Rationale: Because fever can lead to excessive perspiration and evaporation of body fluid via the skin, the nurse should monitor the patient's overall intake and output to be sure that the patient remains in proper fluid balance. Pain, oxygen saturation, and level of consciousness will also be monitored as with all patients, but intake and output are the priority for this patient.

The home care nurse visits an 84-yr-old woman with pneumonia after her discharge from the hospital. Which age-related change in the musculoskeletal system should the nurse expect? A. Positive straight-leg-raising test B. Muscle strength is scale grade 3/5 C. Lateral S-shaped curvature of the spine D. Fingers drift to the ulnar side of the forearm

B. Muscle strength is scale grade 3/5 Decreased muscle strength is an age-related change of the musculoskeletal system caused by decreased number and size of the muscle cells. The other assessment findings indicate musculoskeletal abnormalities. A positive straight-leg-raising test indicates nerve root irritation from intervertebral disk prolapse and herniation. An ulnar deviation or drift indicates rheumatoid arthritis due to tendon contracture. Scoliosis is a lateral curvature of the spine.

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? A. Skin is hard with a dry, waxy white appearance. B. Skin is shiny and red with clear, fluid-filled blisters. C. Skin is red and blanches when slight pressure is applied. D. Skin is leathery with visible muscles, tendons, and bones.

B. Skin is shiny and red with clear, fluid-filled blisters. Deep partial-thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial-thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

The nurse is caring for a patient admitted for uncontrolled seizures who also has impetigo on the face and neck. Which action is appropriate for the nurse to take? A. Put on a protective gown before entering the room. B. Wash hands for 1 to 2 minutes when leaving the room. C. Wear gloves to leave a diet menu on the patient's table. D. Wear a particulate mask when within 3 feet of the patient.

B. Wash hands for 1 to 2 minutes when leaving the room. Rationale: Impetigo is a bacterial skin infection with group A β-hemolytic streptococci or staphylococci. Meticulous hygiene (including hand washing) is essential to prevent the spread of infection. A particulate mask or a gown would not be necessary to prevent the spread of impetigo. Gloves would not be needed to make a delivery to the room.

A patient arrives in the emergency department reporting fever for 24 hours and lower right quadrant abdominal pain. After laboratory studies are performed, what does the nurse determine indicates the patient has a bacterial infection? A. Increased platelet count B. Decreased blood urea nitrogen C. Increased number of band neutrophils D. Increased number of segmented myelocytes

C. Increased number of band neutrophils Rationale: The finding of an increased number of band neutrophils in circulation is called a shift to the left, which is common in patients with acute bacterial infections. Platelets increase with tissue damage through the inflammatory process and for healing but are not the best indicator of infection. Blood urea nitrogen is unrelated to infection unless it is in the kidney. Myelocytes increase with infection and mature to form band neutrophils, but they are not segmented. Mature neutrophils are segmented.

The nurse assesses impaired skin integrity in this patient. How will the nurse document this? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4

C. Stage 3 Rationale: Stage 3 pressure injuries are defined as full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage 1 injuries have intact skin with nonblanchable redness of a local area with a change in skin temperature, tissue consistency, or sensation. Stage 2 injuries are partial thickness with a red-pink wound bed. Stage 4 injuries involve extensive destruction of tissue with exposed bone, tendon, or muscle.

The nurse is providing care to a patient with an open abdominal wound after surgery. What teaching should the nurse provide to the patient regarding the healing process? A. The wound will be stapled together until it heals. B. The healing will contract the area to close the wound. C. The wound will be left open and heal from the edges inward. D. The wound will be sutured after the current infection is controlled.

C. The wound will be left open and heal from the edges inward. Rationale: With secondary healing, the wound is left open and heals from the edges inward and from the bottom up. With primary intention, the wound edges are stapled or sutured, and healing occurs until the contraction of the healing area closes the defect and brings the skin edges closer together to form a mature scar. With tertiary healing, the contaminated wound is left open and closed after the infection is controlled.

When assessing a patient who is receiving cefazolin for the treatment of a bacterial infection, which data suggest that treatment has been effective? A. White blood cell (WBC) count of 8000/ìL; temperature of 101° F B. White blood cell (WBC) count of 4000/ìL; temperature of 100° F C. White blood cell (WBC) count of 8500/ìL; temperature of 98.4° F D. White blood cell (WBC) count of 16,500/ìL; temperature of 98.8° F

C. White blood cell (WBC) count of 8500/ìL; temperature of 98.4° F Rationale: This response is correct because both the WBC count and the temperature are within the normal range. A normal WBC is 4000 to 11,000/ìL. An elevated WBC count and fever are indicators of infection.

The nurse is teaching a patient about the application of a topical medication. What should the nurse include as part of the instructions? A. Avoid applying medications directly onto dressings. B. Use a tongue blade whenever the patient's skin integrity allows. C. Avoid covering skin areas where a topical medication has been applied. D. Apply a layer of medication that is just thick enough to ensure coverage.

D. Apply a layer of medication that is just thick enough to ensure coverage. Rationale: Topical medication should be applied in a thin film to clean skin and spread evenly in a downward motion in the direction of hair growth. Medications may be applied directly onto secondary dressings, and regions with medications may be covered. A tongue blade is not normally used for the application of a thin coat.

A patient is postoperative after a breast reduction and arrives for a follow-up appointment at the clinic. The nurse assesses excess soft pink tissue from the surgical incision site. What complication of wound healing does the nurse recognize this to be? A. Adhesion B. Contractions C. Keloid formation D. Excess granulation tissue

D. Excess granulation tissue Rationale: Excess granulation tissue, the excess soft pink tissue on the wound, is what this complication of wound healing is called. Adhesions are bands of scar tissue that form between or around organs. Wound contraction, which is a normal part of healing, is a complication when it results in deformity by shortening the tissue and impairing function. Keloid formation is a great protrusion of scar tissue that extends beyond the wound edges and may be uncomfortable.

The patient brought to the emergency department after a car accident is diagnosed with a femur fracture. What nursing intervention should the nurse implement at this time to decrease risk of a fat embolus? A. Administer enoxaparin (Lovenox). B. Provide range-of-motion exercises. C. Apply sequential compression boots. D. Immobilize the fracture preoperatively.

D. Immobilize the fracture preoperatively. The nurse immobilizes the long bone to reduce movement of the fractured bone ends and decrease the risk of a fat embolus development before surgical reduction. Enoxaparin is used to prevent blood clots, not fat emboli. Range of motion and compression boots will not prevent a fat embolus in this patient.

When the patient is diagnosed with muscular dystrophy, what information should the nurse include in the teaching plan? A. Use prolonged bed rest to decrease fatigue. B. Continuous positive airway pressure will facilitate sleeping. C. An orthotic jacket will limit mobility and may contribute to deformity. D. Remain active to prevent skin breakdown and respiratory complications.

D. Remain active to prevent skin breakdown and respiratory complications. With muscular dystrophy, the patient must remain active for as long as possible. Prolonged bed rest should be avoided because immobility leads to further muscle wasting. An orthotic jacket may be used to provide stability and prevent further deformity. Continuous positive airway pressure (CPAP) may be used as respiratory function decreases before mechanical ventilation is needed to sustain respiratory function.

When the nurse changes the dressing and documents that there is serosanguineous drainage, which type of drainage did she see on the dressing? Look at the attached photo for answer selections

The correct answer is the top left - the gauze that seems the cleanest (Image A) Rationale: Serosanguineous drainage is frequently seen postoperatively and is composed of RBCs and serous fluid so it is a semiclear pink drainage. Serous drainage is a thin, watery drainage. Hemorrhagic drainage is bloody drainage. Purulent drainage consists of WBCs, microorganisms, and other debris that signal an infection.

The nurse is performing a musculoskeletal assessment on an 81-yr-old patient whose mobility has been progressively declining. How should the nurse safely assess range of motion (ROM) in the affected leg? A. Observe the patient's unassisted ROM in the affected leg. B. Perform passive ROM, asking the patient to report any pain. C. Ask the patient to lift progressive weights with the affected leg. D. Move both the patient's legs from a supine position to full flexion.

a. Observe the patient's unassisted ROM in the affected leg. Observing the patient's active ROM is more accurate and safer than lifting weights. Passive ROM should be performed with extreme caution; it may cause harm when performed on older patients.

A patient is about to have a bone scan. In teaching the patient about this procedure, the nurse should include what information? A. "Mild pain is associated with the procedure." B. "Two additional follow-up scans will be required." C. "The procedure takes approximately 15 to 30 minutes." D. "You will need to drink increased fluids after the procedure."

d. "You will need to drink increased fluids after the procedure." Patients are asked to drink increased fluids after a bone scan to aid in excretion of the radioisotope, if not contraindicated by another condition. No follow-up scans are required. Only mild pain may be associated with bone scans related to 1 hour of lying supine.

An injured soldier underwent left leg amputation 2 weeks ago, but now reports shooting pain and heaviness in the left leg. What action by the nurse is supported by research findings? A. Use mirror therapy. B. Give opioid analgesics. C. Rebandage the residual limb. D. Show the patient the leg is gone.

A. Use mirror therapy. Mirror therapy has been shown to reduce phantom limb pain in some patients. Opioid analgesics, rebandaging the residual limb, and showing the patient that the leg is gone may not decrease phantom limb pain.

A nurse performs discharge teaching for a patient after a left hip arthroplasty using the posterior approach. Which statement indicates teaching is successful? A. "Leg-raising exercises are necessary for several months." B. "I should not try to drive a motor vehicle for 2 to 3 weeks." C. "I will not have any restrictions now on hip and leg movements." D. "Blood tests will be done weekly while taking enoxaparin (Lovenox)."

A. "Leg-raising exercises are necessary for several months." Exercises designed to restore strength and muscle tone will be done for months after surgery. The exercises include leg raises in supine and prone positions. Driving a car is not allowed for 4 to 6 weeks. In the posterior approach hip arthroplasties, extremes of internal rotation and 90-degree flexion of the hip must be avoided for 4 to 6 weeks postoperatively. The knees must be kept apart. The patient should never cross the legs or twist to reach behind. To prevent thromboembolism, enoxaparin is administered subcutaneously and can be given at home. Enoxaparin does not require monitoring of the patient's coagulation status.

To which patient should the nurse plan to administer round-the-clock antipyretic drugs? A. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F B. An 82-yr-old patient after hip replacement surgery and a temperature of 100.4°F C. A 14-yr-old patient with infectious mononucleosis and a temperature of 101.6°F D. A 59-yr-old patient with an acute myocardial infarction and a temperature of 99.8°F

A. A 76-yr-old patient with bacterial meningitis and a temperature of 104.2°F Rationale: Moderate fevers (up to 103° F) usually produce few problems in most patients and do not require antipyretic therapy. If the patient is very young or very old, is extremely uncomfortable, or has a significant medical problem (e.g., severe cardiopulmonary disease, brain injury), the use of antipyretics should be considered. High fevers (above 104° F) should be treated with antipyretics. High fevers can damage body cells and cause delirium and seizures.

Which patient has the highest risk of developing melanoma? A. A fair-skinned woman who uses a tanning booth regularly B. A black patient with a family history of breast and colon cancer C. A Hispanic man with psoriasis and eczema that did not respond to treatment D. An adult who had phototherapy as an infant for the treatment of hyperbilirubinemia

A. A fair-skinned woman who uses a tanning booth regularly Rationale: Risk factors for melanoma include a fair complexion and exposure to ultraviolet light. Psoriasis, eczema, short-duration phototherapy, and a family history of other cancers are less likely to be linked to melanoma.

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? A. Administer 100% humidified oxygen. B. Teach the patient deep breathing exercises. C. Encourage the patient to express his feelings. D. Assist the patient to a high Fowler's position.

A. Administer 100% humidified oxygen. Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.

Which patient is most at risk for the development of a pressure injury? A. An older patient who is septic, bedridden, and incontinent B. An obese woman with leukemia who is receiving chemotherapy C. A middle-aged thin man in a halo cast after a motor vehicle accident D. An older adult with type 1 diabetes admitted in diabetic ketoacidosis

A. An older patient who is septic, bedridden, and incontinent Rationale: Persons at risk for the development of pressure injuries include those who are older, incontinent, bed or wheelchair bound, or recovering from spinal cord injuries. Other examples of risk factors include diabetes, fever, immobility, and anemia.

The patient with frostbite on the distal toes of both feet is scheduled for amputation of the damaged tissue. Which assessment finding or diagnostic study is most objective in determining tissue viability? A. Arteriogram showing blood vessels B. Peripheral pulse palpation bilaterally C. Patches of black, indurated, cold tissue D. Bilateral pale, cool skin below the ankles

A. Arteriogram showing blood vessels Arteriography determines viable tissue for salvage based on blood flow observed in real time and is considered the gold standard for evaluating arterial perfusion. Only arteriography determines where tissue perfusion stops, and amputation needs to occur. Bilateral peripheral pulse assessment and areas of black, indurated, cold, and pale skin indicate ischemia.

The nurse admits a 55-year-old woman with multiple sclerosis to a long-term care facility. Which finding represents a safety concern? A. Ataxic gait B. Severe fatigue C. Radicular pain D. Urinary retention

A. Ataxic gait An ataxic gait is a staggering, uncoordinated gait. Fall risk is the highest in those with gait instability and visual or cognitive impairments. The other signs and symptoms (e.g., fatigue, urinary retention, radicular pain) may also occur in the patient with multiple sclerosis.

A 50-yr-old patient reports shoulder discomfort after raking the yard. Which problem should the nurse suspect? A. Bursitis B. Fasciitis C. Sprained ligament D. Achilles tendonitis

A. Bursitis Bursitis is common in adults older than age 40 years and with repetitive motion, such as raking. Plantar fasciitis occurs as a stabbing pain at the heel caused by straining the ligament that supports the arch. Achilles tendonitis is an inflammation of the tendon that attaches the calf muscle to the heel bone and causes pain with walking or running. A sprained ligament occurs when a ligament is stretched or torn from a direct injury or sudden twisting of the joint, not from repetitive motion.

When administered long-term, which medication requires ongoing musculoskeletal assessment? A. Corticosteroids B. β-Adrenergic blockers C. Antiplatelet aggregators D. Calcium-channel blockers

A. Corticosteroids Corticosteroids are associated with avascular necrosis and decreased bone and muscle mass. β-Blockers, calcium-channel blockers, and antiplatelet aggregators are not commonly associated with damage to the musculoskeletal system.

A patient has a plaster cast applied to the right arm for a Colles' fracture. Which nursing action is most appropriate? A. Elevate the right arm on 2 pillows for 24 hours. B. Apply heating pad to reduce muscle spasms and pain. C. Limit movement of the thumb and fingers on the right hand. D. Place arm in a sling to prevent movement of the right shoulder.

A. Elevate the right arm on 2 pillows for 24 hours. The casted extremity should be elevated at or above heart level for 24 hours to reduce swelling or inflammation. The cast should be supported on pillows during the drying period to prevent denting and flattening of the cast. Ice (not heat) should be applied for the first 24 to 36 hours to reduce swelling or inflammation. Active movement of the thumb and fingers should be encouraged to reduce edema and increase venous return. A sling may be used to support and protect the extremity after the cast is completely dry, but the patient should perform active movements of the shoulder to prevent stiffness or contracture.

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions will the nurse include in this patient's care? (Select all that apply.) A. Escharotomy B. Administration of diuretics C. IV and oral pain medications D. Daily cleansing and debridement E. Application of topical antimicrobial agent

A. Escharotomy C. IV and oral pain medications D. Daily cleansing and debridement E. Application of topical antimicrobial agent An escharotomy (a scalpel incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. Pain control is essential in the care of a patient with a burn injury. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion.

A patient is scheduled for arthrocentesis arrives at the outpatient surgery unit and states, "I do not want this procedure done today." Which response by the nurse is most appropriate? A. "When would you like to reschedule the procedure?" B. "Tell me what your concerns are about this procedure." C. "The procedure is safe, so why should you be worried?" D. "The procedure is not painful because an anesthetic is used."

B. "Tell me what your concerns are about this procedure." The nurse should use therapeutic communication to determine the patient's concern about the procedure. The nurse should not provide false reassurance. It is not appropriate for the nurse to conclude the patient is concerned about pain or assume the patient is asking to reschedule the procedure.

The nurse understands that patients have the most difficulties with diarthrodial joints. Which joints are included in this group? (Select all that apply.) A. Hinge joint of the knee B. Ligaments joining the vertebrae C. Gliding joints of the wrist and hand D. Fibrous connective tissue of the skull E. Ball and socket joint of the shoulder or hip F. Cartilaginous connective tissue of the pubis joint

A. Hinge joint of the knee C. Gliding joints of the wrist and hand E. Ball and socket joint of the shoulder or hip The diarthrodial joints include the hinge joint of the knee and elbow, ball and socket joint of the shoulder and hip, pivot joint of the radioulnar joint, and condyloid, saddle, and gliding joints of the wrist and hand. The ligaments and cartilaginous connective tissue joining the vertebrae and pubis joint and the fibrous connective tissue of the skull are synarthrotic joints.

The postoperative patient has dry skin and reports pruritus on both legs. What nursing actions can help stop the itch-scratch cycle? (Select all that apply.) A. Moisturize the skin on the legs. B. Provide a warm blanket and room. C. Administer antihistamines at bedtime. D. Vigorously rub the patient's legs after bathing. E. Cleanse the legs with a saline solution twice daily.

A. Moisturize the skin on the legs. C. Administer antihistamines at bedtime. Rationale: Moisturizing the skin to decrease the dryness and the itch sensation and bedtime antihistamines to decrease a potential allergic reaction and provide some sedation will help the patient sleep since pruritus is often worse at night and the patient needs sleep for healing. Using non-allergic sheets may also help. Anything causing vasodilation, such as warmth or rubbing, should be avoided. Saline solution would only further dry the skin, so it should not be used on the patient's legs.

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? A. Morphine B. Sertraline C. Zolpidem D. Alprazolam

A. Morphine Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control. Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and depression that patients may have.

A patient has been diagnosed with tinea unguium (onychomycosis) under the nails but does not like the oral antifungal medication. What is the best alternate treatment the nurse should describe for her? A. Nail avulsion B. Antifungal cream C. Thinning of fingernails D. Soaking nails in saltwater

A. Nail avulsion Rationale: Nail avulsion is the best alternate treatment to the oral antifungal medication. Antifungal cream is minimally effective. Thinning fingernails is not needed if the tinea unguium is under her toenails. Soaking the nails in saltwater will not be helpful.

The patient with a stage 4 pressure injury on the coccyx will need a skin graft to close the wound. Which postoperative care should the nurse expect to use to facilitate healing? A. No straining of the grafted site. B. The wound will be exposed to air. C. Soft tissue expansion will be done daily. D. The pressure dressing will not be removed.

A. No straining of the grafted site. Rationale: Straining or stretching of the grafted site must be avoided to allow the graft to be vascularized and fixed to the new site for healing. The wound may or may not be exposed to air depending on the type of graft, and the donor site will be covered with a protective dressing to prevent further damage. Soft tissue expansion and pressure dressings will not be used after this wound's skin graft.

A patient with a fracture of the proximal left tibia in a long leg cast reports of severe pain and a prickling sensation in the left foot. The toes on the left foot are pale and cool. Which nursing action is a priority? A. Notify the health care provider immediately. B. Elevate the left leg above the level of the heart. C. Administer prescribed morphine sulfate intravenously. D. Apply ice packs to the left proximal tibia over the cast.

A. Notify the health care provider immediately. Notify the health care provider immediately of this change in patient's condition, which suggests development of compartment syndrome. Pain unrelieved by drugs and out of proportion to the level of injury is one of the first indications of impending compartment syndrome. Changes in sensation (tingling) also suggest compartment syndrome. Because elevation of the extremity may lower venous pressure and slow arterial perfusion, the extremity should not be elevated above heart level. Similarly, the application of cold compresses may result in vasoconstriction and exacerbate compartment syndrome. Administration of morphine may be warranted, but it is not the first priority.

The nurse would assess a patient admitted with cellulitis for what localized manifestation? A. Pain B. Fever C. Chills D. Malaise

A. Pain Rationale: Pain, redness, heat, and swelling are all localized manifestation of cellulitis. Fever, chills, and malaise are generalized, systemic manifestations of inflammation and infection.

The nurse is caring for a patient who had a left total knee arthroplasty to relieve the pain of severe osteoarthritis. What care would be expected postoperatively? A. Progressive leg exercises to obtain 90-degree flexion B. Early ambulation with full weight bearing on the left leg C. Bed rest for 3 days with the left leg immobilized in extension D. Immobilization of the left knee in 30-degree flexion to prevent dislocation

A. Progressive leg exercises to obtain 90-degree flexion The patient is encouraged to engage in progressive leg exercises until 90-degree flexion is possible; continuous passive motion also may be used based on surgeon preference. Early ambulation is implemented, sometimes the day of surgery, but orders are likely to indicate weight bearing as tolerated rather than full weight bearing. Immobilization and bed rest are not indicated. The patient's knee is unlikely to dislocate.

The nurse notes a patient has chills related to an infection. What is the priority action by the nurse? A. Provide a light blanket. B. Encourage a hot shower. C. Monitor temperature every hour. D. Turn up the thermostat in the patient's room.

A. Provide a light blanket. Rationale: Chills often occur in cycles and last for 10 to 30 minutes at a time. They usually signal the onset of a rise in temperature. For this reason, the nurse should provide a light blanket for comfort but avoid overheating the patient.

In a patient admitted with cellulitis of the left foot, which clinical manifestation would the nurse expect to find on assessment of the left foot? A. Redness and swelling B. Pallor and poor turgor C. Cyanosis and coolness D. Edema and brown skin discoloration

A. Redness and swelling Rationale: Cellulitis is a diffuse, acute inflammation of the skin. It is characterized by redness, swelling, heat, and tenderness in the affected area. These changes accompany the processes of inflammation and infection.

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert the nurse to the presence of an inhalation injury? (Select all that apply.) A. Singed nasal hair B. Generalized pallor C. Painful swallowing D. Burns on the upper extremities E. History of being involved in a large fire

A. Singed nasal hair C. Painful swallowing E. History of being involved in a large fire Reliable clues to the occurrence of inhalation injury is the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and dyspnea.

A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? A. Tachycardia B. Restlessness C. Hypokalemia D. Gastrointestinal (GI) distress

A. Tachycardia Albuterol stimulates β-adrenergic receptors in the lungs to cause bronchodilation. However, it is a non-cardioselective agent, so it also stimulates the β-receptors in the heart to increase the heart rate. Restlessness and GI upset may occur but will decrease with use. Hypokalemia does not occur with albuterol.

The nurse is teaching a patient about her medications. With which medication would the nurse teach the patient to avoid prolonged sun exposure? A. Tetracycline B. Ipratropium C. Morphine sulfate D. Oral contraceptives

A. Tetracycline Rationale: Several antibiotics, including tetracycline, may cause photosensitivity. This is not the case with ipratropium, morphine, or oral contraceptives.

A patient reports to the clinic nurse a ring-like itchy rash on the upper leg, low-grade fever, nausea, and joint pain for the past 3 weeks. What question is most important for the nurse to ask the patient? A. "Is the itching worse at night?" B. "Have you had a tick bite recently?" C. "Have you been exposed to pubic lice?" D. "Have you had unprotected sexual contact?"

B. "Have you had a tick bite recently?" Rationale: Symptoms are consistent with Lyme disease caused by the organism Borrelia burgdorferi, which is transmitted by a tick bite. The itching would not necessarily be worse at night. Exposure to pubic lice would cause itching in the genital area and not fever, nausea, and joint pain. Unprotected sexual contact would not cause an isolated itchy rash on the upper leg.

The nurse teaches a patient with chronic kidney disease about several interventions to reduce pruritus associated with dry skin and uremia. Which statement, if made by the patient to the nurse, indicates further teaching is required? A. "I will avoid taking hot showers." B. "I can rub my skin instead of scratching." C. "Menthol can be used to numb the itch sensation." D. "A lubricating lotion right after bathing will help."

B. "I can rub my skin instead of scratching." Rationale: Any activity that causes vasodilation, such as rubbing or bathing and showering in hot water, should be avoided because vasodilation leads to increased itching. Menthol in skin products provides a sensation that may distract the patient from the sensation of itchiness. Applying lotion right after bathing helps retain moisture in the skin.

A patient is scheduled for dual-energy x-ray absorptiometry (DXA). Which statement by the patient indicates understanding of the procedure? A. "The bone density in my heel will be measured." B. "This procedure will not cause any pain or discomfort." C. "I will not be exposed to any radiation during the procedure." D. "I will need to remove my hearing aids before the procedure."

B. "This procedure will not cause any pain or discomfort." DXA is painless and measures the bone mass of spine, femur, forearm, and total body with minimal radiation exposure. A quantitative ultrasound evaluates bone density using ultrasound of the calcaneus (heel). MRI would require removal of objects such as hearing aids that have metal parts.

A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? A. 18% B. 22.5% C. 27% D. 36%

B. 22.5% Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover about 22.5% of the total body surface area.

When teaching the patient in the rehabilitation phase of a severe burn about performing range of motion (ROM), what explanations should the nurse give to the patient? (Select all that apply.) A. The exercises are the only way to prevent contractures. B. Active and passive ROM maintains function of body parts. C. ROM will reassure the patient that movement is still possible. D. Movement promotes mobilization of interstitial fluid back into the vascular bed. E. Active and passive ROM can only be done while the dressings are being changed.

B. Active and passive ROM maintains function of body parts. C. ROM will reassure the patient that movement is still possible. D. Movement promotes mobilization of interstitial fluid back into the vascular bed. Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible are the explanations that should be used. Contractures are prevented with ROM and splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient has already taken analgesics, ROM can and should be done throughout the day.

A postoperative patient is now able to eat and is requesting a snack. What snack should the nurse recommend for the patient that will facilitate wound healing? A. Apple B. Custard C. Popsicle D. Potato chips

B. Custard Rationale: Custard would be the best snack because it is made from milk, egg, sugar, and vanilla. Wound healing is facilitated by protein, carbohydrates, and B vitamins. Custard also contains calcium and a small amount of vitamin A and zinc. The other snacks do not offer this abundance of healing nutrients. Orange juice with the custard would be good to provide the vitamin C and fluid that are also needed for healing.

The nurse completes an admission history for a 73-yr-old man with osteoarthritis scheduled for total knee arthroplasty. Which response is expected when asking the patient the reason for admission? A. Recent knee trauma B. Debilitating joint pain C. Repeated knee infections D. Onset of frozen knee joint

B. Debilitating joint pain The most common reason for knee arthroplasty is debilitating joint pain despite exercise, weight management, and drug therapy. Recent knee trauma, repeated knee infections, and onset of frozen knee joint are not primary indicators for a knee arthroplasty.

An older adult is moving into an independent living facility. What teaching will prevent this patient from being accidentally burned in the new home? A. Encourage her to stop smoking. B. Install tap water anti-scald devices. C. Ensure all meals are cooked for her. D. Be sure she uses an open space heater.

B. Install tap water anti-scald devices. Installing tap water anti-scald devices will help prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner. Cooking for her may be needed at times of illness or in the future, but she is moving to an independent living facility, so at this time she should not need this assistance. Stopping her from smoking may be helpful to prevent burns but may not be possible without the requirement by the facility. Using an open space heater would increase her risk of being burned and would not be encouraged.

The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? A. Subcutaneous (SQ) tetanus toxoid B. Intravenous (IV) morphine sulfate C. Intramuscular (IM) hydromorphone D. Oral oxycodone and acetaminophen

B. Intravenous (IV) morphine sulfate IV medications are used for burn injuries in the emergent phase to rapidly deliver relief and prevent unpredictable absorption that would occur with the IM route. The PO route is not used because GI function is slowed or impaired because of shock or paralytic ileus, although oxycodone and acetaminophen may be used later in the patient's recovery. Tetanus toxoid may be administered but not for pain.

The home care nurse visits a 74-yr-old man diagnosed with Parkinson's disease who fell while walking this morning. What observation is of most concern to the nurse? A. 2 × 6 cm right calf abrasion with sanguineous drainage B. Left leg externally rotated and shorter than the right leg C. Stooped posture with a shuffling gait and slow movements D. Mild pain and minimal swelling of the right ankle and foot

B. Left leg externally rotated and shorter than the right leg Manifestations of hip fracture include external rotation, muscle spasm, shortening of the affected extremity, and severe pain and tenderness in the region of the fracture site. Expected clinical manifestations of Parkinson's disease include a stooped posture, shuffling gait, and slow movements. An abrasion is a soft tissue injury. Mild pain and minimal swelling may occur with a sprain or strain.

A patient underwent amputation below the knee on the left leg after a traumatic accident. Which intervention should the nurse include in the plan of care? A. Sit in a chair for 1 to 2 hours three times each day. B. Lie prone with hip extended for 30 minutes 4 times per day. C. Dangle the residual limb for 20 to 30 minutes every 6 hours. D. Elevate the residual limb on a pillow for 4 to 5 days after surgery.

B. Lie prone with hip extended for 30 minutes 4 times per day. To prevent hip flexion contractures, the patient should lie on the abdomen for 30 minutes 3 or 4 times each day and position the hip in extension while prone. The patient should avoid sitting in a chair for more than 1 hour with hips flexed or having pillows under the surgical extremity. The patient should avoid dangling the residual limb over the bedside to minimize edema.

The nurse is caring for a patient admitted to the nursing unit with osteomyelitis of the tibia. When completing a focused assessment, which symptom should the nurse expect? A. Nausea and vomiting B. Localized pain and warmth C. Paresthesia in the affected extremity D. Generalized bone pain throughout the leg

B. Localized pain and warmth Osteomyelitis is an infection of bone and bone marrow that can occur with trauma, surgery, or spread from another part of the body. Because it is an infection, the patient will exhibit typical signs of inflammation and infection, including localized pain and warmth. Nausea and vomiting and paresthesia of the extremity are not expected to occur. Pain occurs, but it is localized rather than generalized throughout the leg.

Which intervention should the nurse include in the plan of care for a patient who is paraplegic with a stage 3 pressure injury? A. Keep the pressure injury clean and dry. B. Maintain protein intake of at least 1.25 g/kg/day. C. Use a 10-mL syringe to irrigate the pressure injury. D. Irrigate the pressure injury with hydrogen peroxide.

B. Maintain protein intake of at least 1.25 g/kg/day. Rationale: Adequate protein intake (between 1.25 and 1.50 g/kg/day) is needed to promote healing of pressure injuries. Hydrogen peroxide is cytotoxic and should not be used to clean pressure injuries. A 30-mL syringe with a 19-gauge needle will provide optimal pressure (4 to 15 psi) without causing tissue trauma or damage. The pressure injury should be kept moist to aid in healing.

The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? A. Begin IV fluid replacement. B. Monitor for signs of complications. C. Assess and manage pain and anxiety. D. Discuss possible reconstructive surgery.

B. Monitor for signs of complications. Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

How would the nurse explain the process of normal bone remodeling? A. Osteoclasts add canaliculi. B. Osteoblasts deposit new bone. C. Osteocytes are immature bone cells. D. Osteons synthesize organic bone matrix.

B. Osteoblasts deposit new bone. Bone remodeling is achieved when osteoclasts remove old bone and osteoblasts deposit new bone. Osteocytes are mature bone cells, and osteons or Haversian systems create a dense bone structure; however, they are not involved with bone remodeling.

A patient with pneumonia has a fever of 103° F. What nursing actions will assist in managing the patient's febrile state? A. Administer aspirin on a scheduled basis around the clock. B. Provide acetaminophen every 4 hours to maintain consistent blood levels. C. Administer acetaminophen when the patient's oral temperature exceeds 103.5° F. D. Provide drug interventions if complementary and alternative therapies have failed.

B. Provide acetaminophen every 4 hours to maintain consistent blood levels. Rationale: Antipyretics should be given around the clock to prevent acute swings in temperature. ASA would not be the drug of choice because of its antiplatelet action and accompanying risk of bleeding. When treating fever, drug interventions are not normally withheld in lieu of complementary therapies.

A patient had abdominal surgery last week and returns to the clinic for follow-up. The nurse assesses thick, white, malodorous drainage. How should the nurse document this drainage? A. Serous B. Purulent C. Fibrinous D. Catarrhal

B. Purulent Rationale: Purulent drainage consists of white blood cells, microorganisms, and other debris that signal an infection. Serous drainage is a thin, watery, clear or yellowish drainage frequently seen with broken blisters. Fibrinous drainage occurs with fibrinogen leakage and is thick and sticky. Catarrhal drainage occurs when there are cells that produce mucus associated with the inflammatory response.

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? A. Blisters B. Reddening of the skin C. Destruction of all skin layers D. Damage to sebaceous glands

B. Reddening of the skin The clinical appearance of superficial partial-thickness burns includes reddening of the skin, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.

A patient is seen in the emergency department for a sprained ankle. What initial interventions should the nurse teach the patient for treatment of this soft tissue injury? A. Warm, moist heat and massage B. Rest, ice, compression, and elevation C. Antipyretic and antibiotic drug therapy D. Active movement and exercise to prevent stiffness

B. Rest, ice, compression, and elevation Rationale: Rest, ice, compression, and elevation (RICE) is a key concept in treating soft tissue injuries and related inflammation. Heat may be applied 24 to 48 hours after the injury.

The patient has inflammation and reports feeling tired, nausea, and anorexia. The nurse explains to the patient that these manifestations are related to inflammation in what way? A. Local response B. Systemic response C. Infectious response D. Acute inflammatory response

B. Systemic response Rationale: The systemic response to inflammation includes the manifestations of a shift to the left in the WBC count, malaise, nausea, anorexia, increased pulse and respiratory rate, and fever. The local response to inflammation includes redness, heat, pain, swelling, or loss of function at the site of inflammation. There is not an infectious response to inflammation, only an inflammatory response to infection. The acute inflammatory response is a type of inflammation that heals in 2 to 3 weeks and usually leaves no residual damage.

Which patient should the nurse prepare to transfer to a regional burn center? A. A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% B. A 39-yr-old patient with a partial-thickness burn to the right upper arm C. A 53-yr-old patient with a chemical burn to the anterior chest and neck D. A 42-yr-old patient who is scheduled for skin grafting of a burn wound

C. A 53-yr-old patient with a chemical burn to the anterior chest and neck The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to manage this type of trauma. Patients with chemical burns should be referred to a burn center. A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.

The patient has bleeding gums and purpura. What vitamin in these foods should be encouraged as a nutritional aid to these problems? A. Vitamin A in sweet potatoes, carrots, dark leafy greens B. Vitamin C in peppers, dark leafy greens, broccoli, and kiwi C. Vitamin D in canned salmon, sardines, fortified dairy, and eggs D. Vitamin B7 in liver, cauliflower, salmon, carrots

B. Vitamin C in peppers, dark leafy greens, broccoli, and kiwi Rationale: An absence of vitamin C causes symptoms of scurvy, including petechiae, bleeding gums, and purpura. A deficiency of vitamin B7 (biotin) may result in rashes and alopecia. Vitamins A is needed for wound healing. Vitamin D is needed for bone and body health.

A patient is admitted with a diagnosis of cellulitis of the left leg and has been placed on antibiotics. Which laboratory result is the best indicator that the treatment is having a positive outcome for the patient? A. WBC of 2,900/μL B. WBC of 8,200/μL C. WBC of 12,700/μL D. WBC of 16,300/μL

B. WBC of 8,200/μL Rationale: The normal white blood cell count is generally 4000 to 11,000/μL. For this reason, the patient's level would be returning to normal if it was 8200/μL, indicating recovery from cellulitis. The 2900/µL is too low and indicates another problem is occurring. The 12,700/µL and 16,300/µL are evidence of continuing infection.

The nurse is providing preoperative teaching for the patient having a facelift (rhytidectomy) surgery. Which patient response indicates the patient understands the teaching? A. "I am afraid of the pain afterwards, while it is healing." B. "I can't wait to have my forehead and lip wrinkles eliminated." C. "I have some time off work so I will not look so bad when I go back." D. "Now I can be excited to go to my fiftieth high school reunion this week."

C. "I have some time off work so I will not look so bad when I go back." Rationale: A rhytidectomy or face-lift surgery will not have immediate results and will take time to heal, so taking time off from work will allow more healing to be accomplished before returning to work. There is not much pain with most cosmetic surgeries. A rhytidectomy will not eliminate forehead lines and vertical lip wrinkles.

The nurse is teaching about skin cancer prevention at the community center. Which person is most at risk for developing skin cancer? A. A 67-yr-old bald man with psoriasis and type 2 diabetes. B. A 76-yr-old Hispanic man who has a latex allergy and numerous acrochordons. C. A 55-yr-old woman with fair skin and red hair and a family history of skin cancer. D. A 62-yr-old woman with chronic kidney disease who has blond hair with pale skin.

C. A 55-yr-old woman with fair skin and red hair and a family history of skin cancer. Rationale: Risk factors for skin cancer include having fair skin (with red hair) and a family history of skin cancer. Allergies, acrochordons (skin tags), psoriasis, type 2 diabetes, and chronic kidney disease are not risk factors associated with the development of skin cancer.

A patient presents to the clinic after tripping on a curb and spraining the right ankle. Which initial care measures are appropriate? (Select all that apply.) A. Apply ice directly to the skin. B. Apply heat to the ankle every 2 hours. C. Administer anti-inflammatory medication. D. Compress ankle using an elastic bandage. E. Rest and elevate the ankle above the heart. F. Perform passive and active range of motion.

C. Administer anti-inflammatory medication. D. Compress ankle using an elastic bandage. E. Rest and elevate the ankle above the heart. Appropriate care for a sprain is represented with the acronym RICE (rest, ice, compression, and elevation). Anti-inflammatory medication should be used to decrease swelling if not contraindicated for the patient. After the injury, the ankle should be immobilized and rested. Prolonged immobilization is not required unless there is significant injury. Ice is indicated but will cause tissue damage if applied directly to the skin. Apply ice to sprains as soon as possible and leave in place for 20 to 30 minutes at a time. Moist heat may be applied 24 to 48 hours after the injury.

The unlicensed assistive personnel (UAP) is assisting the patient with Crohn's disease with perineal care. The UAP tells the nurse that the patient had feces coming from the vagina. What is the priority action by the nurse? A. Notify the health care provider. B. Document the fistula formation. C. Assess the patient and vaginal drainage. D. Have the UAP apply a dressing to the vagina.

C. Assess the patient and vaginal drainage. Rationale: With Crohn's disease, a fistula may have formed between the bowel and the vagina. The nurse should first assess the patient and drainage from the vagina. Then the nurse should notify the health care provider, document the occurrence and care provided, describe interventions prescribed, and document the care and patient response.

A patient has been provided with a compression dressing in an attempt to facilitate rapid healing of an ankle sprain. What is a priority nursing assessment? A. Frequent examination of the character and quantity of exudate B. Monitoring for signs and symptoms of local or systemic infections C. Assessment of the patient's circulation distal to the location of the dressing D. Assessment of the range of motion of the ankle and the patient's activity tolerance

C. Assessment of the patient's circulation distal to the location of the dressing Rationale: Any compression dressing requires vigilant assessment of the circulation distal to the dressing site because tissue and nerve damage is a significant risk. This supersedes the importance of assessing the patient's mobility. Exudate and infection would not normally accompany a soft tissue injury such as a sprain.

A 63-yr-old woman with a kidney transplant has been taking prednisone (Deltasone) daily for several years to prevent organ rejection. Which finding is most important for the nurse to communicate to the health care provider? A. Staggering gait B. Ruptured tendon C. Back or neck pain D. Tardive dyskinesia

C. Back or neck pain Osteoporosis with fractures is a serious complication of corticosteroid therapy. The ribs and vertebrae fractures cause back and neck pain. Ataxic (staggering) gait is an adverse effect of phenytoin, an antiseizure medication. A rare adverse effect of ciprofloxacin and other fluoroquinolones is tendon rupture, usually the Achilles tendon. Antipsychotics and antidepressants may cause tardive dyskinesia, characterized by involuntary movements of the tongue and face.

A nurse is teaching a patient how to promote healing following abdominal surgery. What should be included in the teaching? (Select all that apply.) A. Take the antibiotic until the wound feels better. B. Take the analgesic every day to promote adequate rest for healing. C. Be sure to wash hands before changing the dressing to avoid infection. D. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. E. Notify the health care provider of redness, swelling, and increased drainage.

C. Be sure to wash hands before changing the dressing to avoid infection. D. Take in more fluid, protein, and vitamins C, B, and A to facilitate healing. E. Notify the health care provider of redness, swelling, and increased drainage. Rationale: Fluid is needed to replace fluid from insensible loss and from exudates as well as the increased metabolic rate. Protein corrects the negative nitrogen balance that results from the increased metabolic rate and that needed for synthesis of immune factors and healing. Vitamin C helps synthesize capillaries and collagen. Vitamin B complex facilitates metabolism. Vitamin A aids in epithelialization. The health care provider should be notified if there are signs of infection. If prophylactic antibiotics are prescribed, they must be taken until they are completely gone. Initially analgesics are taken throughout the day (e.g., every 3 to 4 hours) as needed. Infection must be avoided with aseptic procedures, including washing the hands before changing the dressing.

An older adult patient is transferred from the nursing home with a black wound on her coccyx. What immediate wound therapy does the nurse anticipate providing to this patient? A. Dress it with an absorbent dressing for exudate. B. Handle the wound gently and let it dry out to heal. C. Debride the nonviable, eschar tissue to allow healing. D. Use negative-pressure wound therapy to facilitate healing.

C. Debride the nonviable, eschar tissue to allow healing. Rationale: With a black wound, the immediate therapy should be debridement (surgical, mechanical, autolytic, or enzymatic) to prepare the wound bed for healing. Black wounds may have purulent drainage, but debridement is done first (except for dry, stable necrotic feet or heels). The red wound is handled gently because it is granulating and re-epithelializing, but it must be kept slightly moist to heal. The negative-pressure wound therapy is used to remove drainage and is more likely to be used after debridement.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? A. Mannitol 75 gram IV B. Urine for myoglobulin C. Lactated Ringer's solution at 25 mL/hr D. Sodium bicarbonate 24 mEq every 4 hours

C. Lactated Ringer's solution at 25 mL/hr Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's solution at 2 to 4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.

The nurse is caring for a patient with osteoarthritis scheduled for total left knee arthroplasty. Preoperatively, the nurse assesses for which contraindication to surgery? A. Pain B. Left knee stiffness C. Left knee infection D. Left knee instability

C. Left knee infection The patient must be free of infection before total knee arthroplasty. An infection in the joint could lead to even greater pain and joint instability, requiring more extensive surgery. The nurse must assess the patient for signs of infection, such as redness, swelling, fever, and elevated white blood cell count. Pain, knee stiffness, or instability are typical of osteoarthritis.

A patient with type 2 diabetes is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? A. Replace the blood lost. B. Maintain a neutral pH. C. Maintain fluid balance. D. Replace serum potassium.

C. Maintain fluid balance. This patient most likely has hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.

The nurse is completing discharge teaching with a patient who is recovering from a right total hip arthroplasty by posterior approach. Which patient action indicates further instruction is needed? A. Uses an elevated toilet seat. B. Sits with feet flat on the floor. C. Maintains hip in adduction and internal rotation. D. Verifies need to notify future caregivers about the prosthesis.

C. Maintains hip in adduction and internal rotation. The patient should not force hip into adduction or internal rotation because these movements could dislocate the hip prosthesis. Sitting with feet flat on the floor (avoiding crossing the legs), using an elevated toilet seat, and notifying future caregivers about the prosthesis indicate understanding of discharge teaching.

A patient admitted with cellulitis and probable osteomyelitis received an injection of radioisotope at 9:00 AM prior to a bone scan. Which statement by the nurse is correct? A. "The scan will be done in 1 hour at 10:00 AM." B. "Decreased isotope uptake is seen with osteomyelitis." C. "The procedure takes around 10 minutes to complete." D. "The isotopes injected for the scan are not harmful to you."

D. "The isotopes injected for the scan are not harmful to you." The isotope does not harm the patient. A technician administers a calculated dose of a radioisotope 2 hours before a bone scan. If the patient was injected at 9:00 AM, the procedure should be done at 11:00 AM. Increased isotope uptake indicates osteomyelitis. Bone scans are completed in about 1 hour.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? A. The total 24-hour fluid requirement should be administered in the first 8 hours. B. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. C. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. D. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.

C. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.

A patient presents with a flat, dry, scaly area on the eyebrows that is treated with a chemical peel. What should the nurse include in the discharge teaching? A. Metastasis of this type of lesion is rare. B. The patient has an increased risk for melanoma. C. Recurrence of the premalignant lesion is possible. D. Untreated lesions may metastasize to regional lymph nodes.

C. Recurrence of the premalignant lesion is possible. Rationale: The flat or elevated dry scaly area is actinic keratosis from sun damage and is a premalignant skin lesion common in older whites with possible recurrence even with adequate treatment. Metastasis of basal cell carcinoma is rare; it is a small slowly enlarging papule. There is an increased risk for melanoma with atypical or dysplastic nevi. With squamous cell carcinoma, untreated lesions may metastasize to regional lymph nodes and distant organs, but it has a high cure rate with early detection and treatment.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? A. Sit or lie in the position of comfort. B. Wear a pressure garment for 8 hours each day. C. Refer the patient to a counselor for psychosocial support. D. Use the sun to increase the skin color on the healed areas.

C. Refer the patient to a counselor for psychosocial support. In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the patient looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours/day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.

The nurse is performing a skin assessment for an older adult patient. What finding should the nurse immediately report to the health care provider? A. The presence of wrinkles on the face and hands. B. The patient's report of dry skin that is frequently itchy. C. The presence of an irregularly shaped mole that the patient states is new. D. The presence of veins on the back of the patient's leg that are blue and tortuous

C. The presence of an irregularly shaped mole that the patient states is new. Rationale: The presence of an irregular mole that is new is suggestive of a neoplasm and warrants immediate reporting and follow-up. Age-related changes may occur that involve the decrease in skin oils that may cause dry skin that itches. Blue and tortuous veins may be unsightly for the patient but are a normal age-related change. Wrinkles are a normal age-related change.

The nurse assesses small, firm, reddened raised lesions with flat, rough patches on a patient that are causing intense pruritus. What question should the nurse next ask the patient? A. "Have you started any new medications?" B. "Do you have a history of seasonal allergies?" C. "Have you had any lesions such as this before?" D. "Tell me about your activities the past 2 to 7 days."

D. "Tell me about your activities the past 2 to 7 days." Rationale: The patient's lesions are papules and plaques characteristic of contact dermatitis. The nurse should ask the patient about activities over the past 2 to 7 days to identify potential allergens because contact dermatitis has a delayed onset. Even if an offending agent is not identified, the nurse can provide patient teaching about managing the pruritus and preventing infection by decreasing scratching. Seasonal allergies and new medications are more likely to cause urticaria than papules and plaque. The nurse should also ask about pruritic rashes in the past to determine potential illnesses that can cause dermatologic manifestations.

An 82-yr-old patient is frustrated by loose abdominal tissue and rigid hips. How should the nurse respond? A. "You should go on a diet and exercise more to feel better about yourself." B. "Something must be wrong with you because you should not have these problems." C. "You have arthritis and need to take nonsteroidal antiinflammatory drugs (NSAIDs)." D. "Decreased muscle mass and strength and increased hip rigidity are expected with aging."

D. "Decreased muscle mass and strength and increased hip rigidity are expected with aging." The musculoskeletal system's normal changes of aging include decreased muscle mass and strength; increased rigidity in the hips, neck, shoulders, back, and knees; decreased fine motor dexterity; and slowed reaction times. Going on a diet and exercising will help but not stop these changes. Telling the patient "Something must be wrong with you..." is untrue and will not be helpful to the patient's frustrations.

A patient who had a long leg cast applied this morning asks to crutch walk before dinner. Which statement explains why the nurse will decline the patient's request? A. "You must ambulate with a physical therapist for the first few days." B. "The cast is not dry yet, so it may be damaged while using crutches." C. "Rest, ice, compression, and elevation are in process to decrease pain." D. "Excess edema and complications are prevented when the leg is elevated for 24 hours."

D. "Excess edema and complications are prevented when the leg is elevated for 24 hours." For the first 24 hours after a lower extremity cast is applied, the leg should be elevated on pillows above heart level to avoid excessive edema and compartment syndrome. RICE is used for soft tissue injuries, not with long leg casts.

A 21-yr-old soccer player has injured the anterior crucial ligament (ACL) and is having reconstructive surgery. Which patient statement indicates more teaching is required? A. "I probably won't be able to play soccer for 6 to 8 months." B. "They will have me do range of motion with my knee soon after surgery." C. "I will need to wear an immobilizer and progressively bear weight on my knee." D. "I can't wait to get this done now so I can play in the soccer tournament next month."

D. "I can't wait to get this done now so I can play in the soccer tournament next month." The patient does not understand the severity of ACL reconstructive surgery if planning to resume playing soccer soon; safe return will not occur for 6 to 8 months. A physical therapist will oversee initial range of motion, immobilization, and progressive weight bearing.

A patient tells the nurse that they are afraid to use the treatment recommended for psoriasis. What is the best response by the nurse? A. "You will only know if you try it and see." B. "You may need to get counseling to help you cope." C. "No treatment is medically necessary, but it can be removed." D. "Topical, light therapy, and systemic medications are now available."

D. "Topical, light therapy, and systemic medications are now available." Rationale: Treatment of psoriasis usually involves a combination of strategies, including topical treatments; phototherapy; and/or systemic medications, including biologic drugs. Telling her that she will only know if she tries or that she may need counseling is denying the patient's concern. Psoriasis is treated to manage the disease as the patient may have a weakened immune system and be at risk for cardiovascular disease.

The nurse recognizes that which patient is likely to have the poorest prognosis? A. A patient with nodular ulcerative basal cell cancer. B. A patient who has been diagnosed with late squamous cell cancer. C. A patient whose is being treated for superficial squamous cell cancer. D. A patient who is newly diagnosed with stage IV malignant melanoma.

D. A patient who is newly diagnosed with stage IV malignant melanoma. Rationale: Late detection of melanoma is associated with a poor outcome. Basal cell cancers often have very high treatment success rates. Although late squamous cell cancer (SCC) has worse outcomes than superficial SCC, these are both exceeded in mortality rates by late-stage melanoma.

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? A. Serum sodium and potassium increase. B. Serum sodium and potassium decrease. C. Edema and arterial blood gases improve. D. Diuresis occurs and hematocrit decreases.

D. Diuresis occurs and hematocrit decreases. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation. The hemolysis of red blood cells (RBCs) and thrombosis of burned capillaries also decreases circulating RBCs. When the fluid balance has been restored, dilution causes the hematocrit levels to drop. Initially sodium moves to the interstitial spaces and remains there until edema formation ceases, so sodium levels increase at the end of the emergent phase as the sodium moves back to the vasculature. Initially potassium level increases as it is released from injured cells and hemolyzed RBCs, so potassium levels decrease at the end of the emergent phase when fluid levels normalize.

The nurse determines that an older adult patient recovering from left total knee arthroplasty has impaired physical mobility from decreased muscle strength. What nursing intervention is appropriate? A. Promote vitamin C and calcium intake in the diet. B. Provide passive range of motion to all the joints every 4 hours. C. Keep the left leg in extension and abduction to prevent contractures. D. Encourage isometric quadriceps-setting exercises at least 4 times a day.

D. Encourage isometric quadriceps-setting exercises at least 4 times a day. Emphasis is placed on postoperative exercise of the affected leg, with isometric quadriceps setting beginning on the first day after surgery. Vitamin C and calcium do not improve muscle strength, but they will facilitate healing. The patient should be able to perform active range of motion to all joints. Keeping the leg in one position (extension and abduction) may contribute to contractures.

The nurse is caring for a patient who is immunocompromised while receiving chemotherapy for advanced breast cancer. What signs and symptoms will the nurse teach the patient to report that may indicate an infection? A. Fever and chills B. Increased blood pressure C. Increased respiratory rate D. General malaise and fatigue

D. General malaise and fatigue Rationale: An immunosuppressed patient may have the classic symptoms of inflammation or infection masked by the inability to launch a normal immune response. Therefore, in this person, early symptoms may be malaise, fatigue, or "just not feeling well."

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? A. Full liquids only B. Whatever the patient requests C. High-protein and low-sodium foods D. High-calorie and high-protein foods

D. High-calorie and high-protein foods A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.

The nurse is teaching the residents of an independent living facility about preventing skin infections and infestations. What should be included in the teaching? A. Use cool compresses if an infection occurs. B. Oral antibiotics are needed for any skin changes. C. Antiviral agents will be needed to prevent outbreaks. D. Inspect skin for changes when bathing with mild soap.

D. Inspect skin for changes when bathing with mild soap. Rationale: Persons living in independent living facilities are usually older, which means their skin does not need cleaning with hot water and vigorous scrubbing or as often as a younger person. Mild soap (e.g., Ivory) should be used to avoid loss of protection from neutralization of the skin's surface. The skin should be inspected for changes with bathing. Cool compresses are used with ringworm or stings for the antiinflammatory effect. Oral antibiotics are used for Lyme disease from ticks. Antiviral agents are used for viral infections but not to prevent outbreaks.

The nurse is caring for a patient placed in Buck's traction before open reduction and internal fixation of a left hip fracture. Which care can be delegated to the LPN/VN? A. Assess skin integrity around the traction boot. B. Determine correct body alignment to enhance traction. C. Remove weights from traction when turning the patient. D. Monitor pain intensity and administer prescribed analgesics.

D. Monitor pain intensity and administer prescribed analgesics. The LPN/VN can monitor pain intensity and administer analgesics. Assessment of skin integrity and determining correct alignment to enhance traction are within the RN scope of practice. Removing weights from the traction should not be delegated or done. Removal of weights can cause muscle spasms and bone misalignment and should not be delegated or done.

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? A. Severe pain, blisters, and blanching with pressure B. Pain, minimal edema, and blanching with pressure C. Redness, evidence of inhalation injury, and charred skin D. No pain, waxy white skin, and no blanching with pressure

D. No pain, waxy white skin, and no blanching with pressure With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.

A 67-yr-old patient hospitalized with osteomyelitis has an order for bed rest with bathroom privileges and elevation of the affected foot on 2 pillows. The nurse would place the highest priority on which intervention? A. Ambulate the patient to the bathroom every 2 hours. B. Ask the patient about preferred activities to relieve boredom. C. Allow the patient to dangle legs at the bedside every 2 to 4 hours. D. Perform frequent position changes and range-of-motion exercises.

D. Perform frequent position changes and range-of-motion exercises. The patient is at risk for atelectasis of the lungs and contractures because of prescribed bed rest. For this reason, the nurse should place the priority on changing the patient's position frequently to promote lung expansion and performing range-of-motion exercises to prevent contractures. Assisting the patient to the bathroom will keep the patient safe as the patient is in pain, but it may not be needed every 2 hours. Providing activities to relieve boredom will assist the patient to cope with the bed rest. Dangling the legs every 2 to 4 hours may be too painful.